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What Is a DRG for Medical Billing?

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Defined by the Centers for Medicare and Medicaid Services, diagnosis-related groups or DRGs are categories of clinical conditions that occur together. For example, if thrush is diagnosed as a result of HIV infection, both pathologies would be found in one DRG.

Purpose

If a medical complication or surgical procedure is a result of another diagnosis, the cost of treating the secondary complication or procedure varies greatly from when the condition exists alone or as the result of a different anomaly. This is why a medical biller's job of assigning accurate DRGs is essential to the reimbursement of Medicare providers.

Assignment

The following medical record information is used to determine the assignment of DRGs: gender, age, principal diagnosis, secondary diagnoses, surgeries and patient state at discharge.

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Top Five Diagnosis-related Groups

Five of the top 10 diagnosis-related groups reported by CMS include heart failure and shock, angina pectoris, psychoses, chronic obstructive pulmonary disease, and cerebrovascular disorders.

About the Author

Sarah McLeod began writing professionally for the federal government In 1999. In 2002 she was trained by Georgetown University's Oncology Chief to abstract medical records and has since contributed to Phase I through Phase IV research around the country. McLeod holds a Bachelor of Arts in human services from George Washington University and a Master of Science in health science from Touro University.

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